The Perfect Storm: Severe Penicillin Reaction Three Weeks After Intrapartum Antibiotic Prophylaxis

Background:

Because of the devastation of early onset group B streptococcal (GBS) infection in the neonate, intrapartum antibiotic prophylaxis (IAP) has been recommended since 1996 for colonized women. Administration of at least two doses of intravenous penicillin prior to birth has significantly reduced the incidence of neonatal GBS disease. Penicillin is a common drug, sometimes causing adverse effects and allergic responses. Risk factors for developing drug allergies include age, gender, route of administration, frequent administration of antibiotics and presence of other allergies.  Women receiving IAP may be at risk for developing penicillin allergy.  

Case:

A multipara (G4P3) received IAP after testing positive for GBS on routine late term screening.  She also had received IAP as recommended by CDC guidelines during her previous three labors.  She had a normal physiologic labor and birth for her fourth child, a healthy girl. She initiated breast-feeding right after birth. Three weeks following birth, she developed mastitis and was prescribed oral dicloxacillin. Seven days after starting this drug, she experienced significant uticaria, pruritis and angioedema. She had swelling of the lips and face but did not experience respiratory distress.  In the emergency room, she was given a dose of oral prednisone and discharged.  She discontinued the dicloxacillin as instructed by the emergency care provider.  Within 18 hours she reported back to the emergency room with increased severity of symptoms. At this time, she was started on high doses of steroids, hydroxyzine and antihistamines and referred to an immunologist.

Conclusion:

While IAP has been effective in reducing early onset GBS disease in the neonate, infusion of penicillin in healthy childbearing women may increase their risk of penicillin allergy, especially when penicillin or a related drug is administered shortly thereafter. Several consequences of this newly acquired allergy have nursing implications. Careful history is necessary when women report drug allergies, as most people who state having a drug allergy do not when tested.  This underscores the importance of a good history and accurate patient records. Nurses were important in providing her education about allergic reactions, giving comfort measures for her symptoms, and assisting her with pumping as she had to discard pumped milk that was laden with drugs.  Assisting her to find formula and nipple that her completely breast-fed baby tolerated was important nursing care. Finally, it was important that she understood SAFE care (Seek help, Allergen identification, Follow-up care, and Epinephrine for emergencies).

Keywords:

Allergy, Antibiotics, Intrapartum